Can ACT Reduce the Use of Sick Leave and Medical Services in Workers at Risk for Long-Term Disability?

Sitting, standing, or walking for long hours. Hammering, drilling, brooming. Pushing or lifting weights. Tending to elderly or disabled patients. Teaching to a large class of children. Most occupations and jobs involve repetitive tasks that may cause physical and mental discomfort with negative impact on health and wellbeing. Physical and mental demands can be particularly high for some health professions like nursing, leading to absenteeism, increased sick leave and medical utilization, and higher risk of long-term disability (1, 2). 

Although adapting to these demands can be difficult, different cognitive and behavioral strategies have the potential to lessen the burden and improve performance both at work and in daily life activities. A key goal of these approaches, which include Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and related interventions, is to increase exposure to conditions and situations that trigger stress and pain, thus reducing avoidance and fear to achieve greater behavioral flexibility in their presence (3).

ACT emphasizes the need to observe thoughts and feelings as they are, without trying to change them, to modify behaviors in ways consistent with valued goals and life directions. ACT aims not to reduce actual pain or stress, but to make them more manageable by altering the client’s relationship with the symptoms and beliefs that surround them. Thus, the ACT intervention does not necessarily intend for symptoms reduction, but that the client is able to act effectively, and flexibility, even if symptoms persist. 

ACT intervention does not necessarily intend for symptoms reduction, but that the client is able to act effectively, and flexibility, even if symptoms persist.  Click To Tweet

Can ACT Improve Function Despite Stress and Pain?

“Traditional medical interventions have aimed their efforts at directly reducing the experience of stress and pain. But, is it the case that taking this adversarial posture with respect to stress and pain leads to the best possible functioning?”

Such is the question that a study carried out in Sweden and published in Behavior Therapy tried to answer, by examining whether a brief Acceptance and Commitment Therapy (ACT) intervention would reduce sick leave utilization, medical demand, and increase quality of life in public health sector workers with chronic stress/pain who were at risk for long-term disability (4).

All but 2 participants (17 women and 2 men) were nurses or mental health workers with (a) daily stress symptoms exceeding 60% maximum ratings on a cluster of 15 stress symptoms; (b) daily pain ratings of 7 or more on the VAS scale; and (c) a score of 8 or above on a rating of the participants’ belief that their symptoms were caused by work (a major predictor of long-term sick leave). 

Participants were randomly assigned into 2 groups: 

Medical treatment as usual (MTAU): Participants in this group (n  = 8) received a variety of medical resources including physician, specialist, and physical therapy visits, provided free of charge by the Swedish healthcare system. 

MTAU plus ACT: Participants (n = 11) were allowed ongoing free access to MTAU and were also provided with four 1-hour individual sessions of ACT conducted weekly at the work site or at home. Over the sessions, four ACT components (values, defusion, exposure, and commitment), and their associated exercises, were covered as described in the seminal work on ACT by Hayes, Strosahl, and Wilson (1999) (5). 

Two therapists provided the ACT intervention. One was an experienced CBT psychotherapist, who received didactic and experiential ACT training provided by K. Wilson, a study’s author and developer of this treatment. The second therapist was a registered nurse with no formal psychotherapy training who worked under the supervision of the CBT therapist. All subjects in both groups had access to MTAU throughout the baseline (6 months), intervention (1 month), and follow-up (6 months) periods.

Study Results

Sick leave utilization. There was a very low level of sick leave use (4 days on average) in both groups during the 6-month baseline prior to the intervention. During the intervention month, the ACT group took significantly fewer days of sick leave (1 day on average) than the MTAU group, which showed a large spike in sick leave usage (11.5 days on average). At 6-month follow-up, these numbers were further reduced to 0 to 1 day per month in the ACT group, but increased dramatically (7.5 to 10.5 days per month) for MTAU participants.

Medical treatment. There was no difference between groups in the number of medical visits recorded during the baseline and intervention periods. However, significantly less medical visits were required by ACT participants during the 6-month follow-up for ACT (1.9 medical visits on average) compared to MTAU (15.1 visits).

Remarkably, these improvements in sick leave and medical utilization could not be accounted for by remission of stress and pain in the ACT group, because no significant differences between interventions were found in levels of pain, stress, or quality of life. 

ACT Can Alter the Relationship with Pain. But is it Enough?

The study’s results seemed to support the hypothesis that “the addition of ACT to medical treatment-as-usual would lead to less focus on symptoms and more focus on valued domains of living and that this change would result in increased quality of life and less use of both sick leave and medical treatment.” (4)

The authors point out that “ACT did not target stress and pain for intervention. Instead, the intervention was aimed at altering the client’s relationship with stress and pain. If ACT works in the ways that have been suggested here, functioning should improve with some degree of independence from level of stress and pain symptoms”.

This seemed to be the case, as ACT promoted a mindset change towards better tolerance to pain and stress, or improved ways to manage them. It is unclear, however, whether increased functioning levels among participants were sustained, or if the intervention decreased -or even increased, due to the higher workload- the levels of pain, stress, and disability over time. 

ACT Can Alter the Relationship with Pain. But is it Enough? Click To Tweet

An Integral Approach to a Complex Problem

Aided by persisting, adverse work conditions and/or personal habits, stress and pain can become recurrent and growing problems; therefore the need to address both potential causes of discomfort at work and lifestyle habits that may trigger or reinforce them. An integral approach to tackle the multidimensional nature of chronic pain should try to identify its root causes, the psychological factors that shape its experience, and tailor a therapeutic and management plan to effectively target them. 

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What Can Physical Therapists Do?

Physical Therapy has an extraordinary potential to address all these aspects, and to play a primary preventive role against chronic pain and disease. Evidence shows that long term improvement for common chronic pain conditions is greatly helped by lifestyle adjustments, key among these, nutrition and exercise (6). 

Complementing these changes, psychological approaches like ACT and CBT can help define a comprehensive treatment and prevention plan to lessen pain and stress symptoms, recover movement and function, and live a more active and fulfilling life.  

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1- Klein, M., Wobbe-Ribinski, S., Buchholz, A., Nienhaus, A., & Schablon, A. (2018). Nurse-work instability and incidence of sick leave–results of a prospective study of nurses aged over 40. Journal of Occupational Medicine and Toxicology, 13(1), 31.

2- Kisakye, A. N., Tweheyo, R., Ssengooba, F., Pariyo, G. W., Rutebemberwa, E., & Kiwanuka, S. N. (2016). Regulatory mechanisms for absenteeism in the health sector: a systematic review of strategies and their implementation. Journal of healthcare leadership, 8, 81–94. doi:10.2147/JHL.S107746

3- Dahl, J., & Lundgren, T. (2006). Acceptance and commitment therapy (ACT) in the treatment of chronic pain. Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications, 285-306.

4- Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior therapy, 35(4), 785-801.

5- Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: The Guilford Press

6- Dean, E., & Söderlund, A. (2015). What is the role of lifestyle behaviour change associated with non-communicable disease risk in managing musculoskeletal health conditions with special reference to chronic pain?. BMC musculoskeletal disorders, 16(1), 87.

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